Nursing Responsibilities

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6-ACOBA,Oliver C.

2NUR-1

5 Nursing responsibilities
Uterine Contraction
Latent Phase:

• Assess patient’s psychological readiness. Help the mother to get comfortable


• Provide encouragement, reassure, and companionship
• Assist with coping methods
• Measure duration of latent phase
• Conduct health teaching on breastfeeding, newborn care, and effective bearing down
because during this time, patient’s anxiety is controlled and she is able to focus on
nurse’s instructions.
Active Phase:

• Inform patient on the progress of her labor to lessen her anxiety and obtain her
trust and cooperation.
• Start monitoring progress of labor with the use of WHO partograph, 2-hour action
line.
• Encourage patient to be continually active to maximize the effect of uterine
contractions. Upright maternal positions are recommended if tolerated.
• Assist patient in assuming her position of comfort. For those who can’t stay
upright, left-side lying is recommended to avoid disruption in fetal oxygenation.
• Monitor maternal vital signs and fetal heart rate every 2 hours, or depending on
the doctor’s order.
Transition Phase:

• Inform patient on progress of her labor.


• Assist patient with pant-blow breathing.
• Monitor maternal vital signs and fetal heart rate every 30 minutes -1 hour, or
depending on the doctor’s order. Contraction monitoring is also continued.
• prepare for delivery. Check room temperature. The nurse should also notify staff and
prepare necessary supplies and equipment.
• perform handwashing and double gloving.

Cervical Dilatation
6-ACOBA,Oliver C.
2NUR-1

Latent Phase: Active Phase: Transition Phase:

• Instruct patient on quality pushing. The abdominal muscles must aid the involuntary
uterine contractions to deliver the baby out.
• Provide a quiet environment for the patient to concentrate on bearing down.
• Provide positive feedback as the patient pushes.
• Repeat doctor’s instructions. At this phase, the patient barely hears the conversation
around the room because all her energy and thoughts are being directed toward giving
birth.
• Take note of the time of delivery and proceed to initiate essential newborn care.
Delayed cord clamping is recommended.
• Assist in restrictive episiotomy for patients who had vaginal births.

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